Treatment Options for OA Flashcards
What joint is spared in osteoarthritis?
Ankle
What is osteoarthritis?
Clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life.
What are the most commonly affected joints?
Knees, hips and small hand joints
OA isn’t always caused by ageing. What else might it be caused by? (2)
Trauma
Metabolic conditions
Describe what is meant by ‘OA is a metabolically active repair process’.
The cartilage is trying to repair the damage, but it isn’t able to. It causes localised loss of cartilage and remodelling of adjacent bone.
What are the symptoms of OA? (5)
Joint pain (with use) Morning stiffness lasting <30 minutes Joint instability or buckling Loss of function Crepitus on motion
What are the signs of OA? (5)
Bony enlargement at affected joints Limited range of motion Crepitus on motion Mal-alignment and/or joint deformity Muscle atrophy/weakness
What do all OA patients have in terms of management?
Information and advice (education, weight loss, exercise, lifestyle alterations)
What do some OA patients have in terms of management?
Simple non-surgical interventions – NSAIDs, other drugs, physiotherapy, occupational therapy, orthoses, other aids
Advanced non-surgical interventions - injections
What do few OA patients have in terms of management?
Surgery (joint preserving) – osteotomy, resurfacing
Surgery – partial or total joint replacement
What are the key priorities for non-pharmacological care? (4)
- Exercise
- TENS (transcutaneous electrical nerve stimulation) as an adjunct for pain relief
- Acupuncture
- Aids and devices to give stability e.g. orthopaedic insoles and walking sticks
- Diet
- Nutriceuticals
What are the benefits of exercise for OA? (4)
Local muscle strengthening
Improves general aerobic fitness
Improves weight loss
Improves bone health and mass
What are nutriceuticals for OA? (3)
Omega-3 rich foods
Chondroitin sulphate supplements
Glucosamine supplements
What is the arthritis prevalence in healthy weight people?
16.9%
What is the arthritis prevalence in overweight people?
19.8%
What is the arthritis prevalence in obese people?
29.6%
How is OA managed pharmacologically? (3)
Oral analgesics - paracetamol and/or topical NSAID, topical capsaicin
Oral NSAID/COX-2 inhibitor - used at lowest effective dose for shortest possible period, standard NSAID 1st then COX-2
Intra-articular injections (corticosteroid injections)
Name a COX-2 inhibitor.
Celecoxib
When are patients considered for referral for surgery?
When pain, stiffness and reduced function have a substantial impact on quality of life i.e. they are waking at night because of the pain.
What are the orthopaedic treatment options? (6)
Arthroscopic lavage Arthroscopic lavage plus debridement Microfracture Mosiacplasty (osteochondral transplant) Chondrocyte grafts Joint replacement
What is done in microfracture surgery?
Creating damage to the articular cartilage in order to induce it to repair itself. Drill into the subchondral bone down to the bone marrow (as this is a pluripotent stem cell population, so can differentiate into chondroblasts).
How long does it take the cartilage to recover from microfracture surgery?
Who has the best results?
4-6 months
Peopleunder age 40 with a recent cartilage injury and those who are not overweight
What is done in arthroscopic lavage and debridement surgery?
Arthroscopic lavage means washing out the joint, and debridement means getting rid of debris. Cleans the surfaces and remove any bits of loose cartilage from the joint that might cause the joint to lock or rub onto surface of the bone. Debridement tidies up the edges so we have a smoother surface.
How many patients who had debridement and washout were pain-free at 1 year?
How many were who just washout?
80-90%
14%
What is responsible for the visco-elastic properties of synovial fluid?
Hyaluronic acid
How is the synovial fluid different in OA? (3)
Lower concentration
Low molecular weight
Reduced viscosity
How many % of OA patients have visco-supplementation treatment currently?
Only about 14%
What are the advantages of visco-supplementation? (4)
Works well at all stages of OA
Improves patient assessed pain
Well tolerated
Long term effectiveness
What are the disadvantages of visco-supplementation? (2)
Severe OA may not respond as well
Some local adverse effects at injection site
How does visco-supplementation work? (2)
Returns higher molecular weight hyaluronans and increases viscosity
Provides direct analgesic effect
How many patients on hyaluronic acid reported none or slight pain in prior 48 hours (compared to those on
naproxen)?
48% (compared to 39% naproxen)
What does chondrocyte grafting involve?
Autologous chondrocytes are grafted to repair larger defects.
The chondrocytes, either from own costal cartilage or from donors, are transplanted/grafted into the required region that has ebonation (exposed bone). A periosteal patch is sown into place on top of the chondrocytes to keep them in place. Over 1-6 months, they will start producing cartilage so bone is no longer exposed. The net result of this is that the defect is filled. This decreases pain and other symptoms, and allows more activity.
What is the advantage of chondrocyte grafting over microfracture surgery?
It tends to produce hyaline cartilage (rather than fibrocartilage created by microfracture, which is less durable/resilient).
What are the sources of chondrocytes for grafting? (3)
Rib costo-chondral process
Non-damaged part of joint
Cartilage implants from young individuals
What does ACI stand for?
Autologous chondrocyte implantation
What is the disadvantage of ACI/chondrocyte grafting?
Can hypertrophy - unreliable biological potential of implanted cells
Why is microfracture not done alone, but with ACI?
Because microfracture alone increases pain and symptoms.
What is meant by mosaicplasty?
Give an example of where it is done.
Taking cartilage and subchondral bone from one area and putting it into another region.
Take biopsy from superior part of femur and graft onto inferior part of femur and tibia.
What is osteotomy?
What joints is it done for?
Realigning the bones/joint surfaces i.e. altering the joint mechanics
Done for big joints
With the knee, which compartment is often affected (that requires osteotomy)?
How is this fixed?
Medial compartment
Take a wedge out of the side of the tibia
If there is a genu valgus deformity, which bone requires osteotomy?
Femur
If there is a genu varus deformity, which bone requires osteotomy?
Tibia
How big is the incision for conventional hip replacements?
How is the joint accessed?
20-30cm
Muscles, ligaments and tendons are cut
How big is the incision for the newer minimal invasive hip replacements?
10cm or less
Why are minimally invasive replacements better?
Smaller incision so less damage to surrounding structures
Which joint replacement is most successful?
Hip
What is a disadvantage of non-cemented replacements?
Require better precision
How long do cemented replacements last?
15-20 years
What is the lifetime risk of needing a total knee replacement?
About 0.3
What are the dangers of joint replacement? (7)
Infection Instability Pain Peri-prosthetic fracture Component failure Aseptic loosening Loosening and movement of the prosthesis
What does SYSADOA stand for?
Symptomatic slow acting drugs for osteoarthritis
What does IA HA stand for?
Intra-articular hyaluronic acid
What makes up the biggest proportion of treatment for OA?
NSAIDs
What are potential future treatments for OA? (4)
Matrix metalloproteinase inhibitors
IL-1 beta converting enzyme inhibitors
Bradykinin receptor antagonist
NF-kappa beta inhibitor
